https://doi.org/10.3889/oamjms.2022.8122 eISSN: 1857-9655
Category: F - Review Articles Section: Meta-analytic Review Article
Meta-Analysis of Laparoscopic Pyelolithotomy versus Percutaneous Nephrolithotomy as a Treatment of Large Kidney Stones
Gede Wirya Kusuma Duarsa1*, Pande Made Wisnu Tirtayasa2, Ida Bagus Putra Pramana2, I. Wayan Yudiana1, Kadek Budi Santosa1, Anak Agung Gde Oka1
1Department of Urology, Faculty of Medicine, Universitas Udayana, Sanglah Hospital, Bali, Indonesia; 2Department of Urology, Faculty of Medicine, Universitas Udayana, Universitas Udayana Hospital, Bali, Indonesia
Abstract
BACKGROUND: Percutaneous nephrolithotomy (PCNL) is considered as a gold standard management for treating large kidney stones. However, laparoscopic approach has been considered as an alternative management to treat such cases.
AIM: The goal of this study is to assess the safety and efficacy of laparoscopic stone removal or laparoscopic pyelolithotomy and PCNL for patients with large kidney stone/s whether they were single or multiple.
METHODS: Authors searched literatures from Medline, EMBASE, Science Direct, Cochrane Library, and Google Scholar published from inception to March 2019. The studies related to laparoscopic pyelolithotomy regardless of the approach and PCNL for the treatment of kidney stones. Meta-analysis was performed following data extraction and quality assessment. Data analysis was performed using Review Manager 5.3.
RESULTS: Sixteen studies with a total of 1044 patients comprised of 501 and 543 patients treated with laparoscopic pyelolithotomy and PCNL, respectively. Operative time was longer in laparoscopic group (Mean difference [MD], 35.45 (95% confidence interval [CI] 13.12–57.79), p = 0.002, I2 = 98%). Stone free rate was higher in laparoscopic than PCNL (RR, 1.17 (95% CI 1.09–1.25), p < 0.0001, I2 = 59%) group. Moreover, patients in laparoscopic group benefited from lesser overall complication (RR, 0.71 (95% CI 0.55–0.93), p = 0.01, I2 = 0%), drop in hemoglobin (MD, −0.89 (95% CI −1.14– (−0.65)), p < 0.00001, I2 = 53%), blood transfusion rate (Risk ratio [RR], 0.33 (95%
CI 0.16–0.66), p = 0.002, I2 = 0%), post-operative fever (RR, 0.45 (95% CI 0.28–0.72), p = 0.0009, I2 = 15%), and the need for additional intervention (RR, 0.35 (95% CI 0.19–0.62), p = 0.0004, I2 = 0%). In addition, there were no significance in post-operative hospital stay (MD, 0.45 (95% CI −0.14–1.03), p = 0.13, I2 = 90%) and prolonged urine leakage (RR, 1.76 (95% CI 0.90–3.42), p = 0.10, I2 = 0%) between two groups.
CONCLUSION: Laparoscopic stone removal provided higher stone free rate and lower post-operative complications than PCNL. Laparoscopic approach could stand as a main treatment option in large kidney stone/s beside PCNL.
Moreover, further Randomized controlled trial studies needed to justify the outcomes of this study.
Edited by: Ksenija Bogoeva-Kostovska Citation: Duarsa GWK, Tirtayasa PMW, Pramana IBP, Yudiana IW, Santosa KB, Oka AAG. Meta-Analysis of Laparoscopic Pyelolithotomy versus Percutaneous Nephrolithotomy as a Treatment of Large Kidney Stones.
Open Access Maced J Med Sci. 2022 Feb 28; 10(F):113-121.
https://doi.org/10.3889/oamjms.2022.8122 Keywords: Laparoscopic pyelolithotomy; Percutaneous nephrolithotomy; Kidney stone
*Correspondence: Gede Wirya Kusuma Duarsa, Department of Urology, Faculty of Medicine Universitas Udayana/Sanglah Hospital, Bali, Indonesia.
E-mail: [email protected] Received: 30-Nov-2021 Revised: 21-Feb-2022 Accepted: 24-Feb-2022 Copyright: © 2022 Gede Wirya Kusuma Duarsa, Pande Made Wisnu Tirtayasa, Ida Bagus Putra Pramana, I. Wayan Yudiana, Kadek Budi Santosa, Anak Agung Gde Oka Funding: This research did not receive any financial support Competing Interests: The authors have declared that no competing interests exist Open Access: This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 International License (CC BY-NC 4.0)
Introduction
For several decades, percutaneous nephrolithotomy (PCNL) is being considered as a gold standard management for most large kidney stone cases. Despite the flourishing advances in PCNL technique, several concerns still reside about its complications such as post-operative bleeding, injury to the neighboring organs, and the parenchymal loss [1]. Some literatures reported that there was no significant effect on glomerular filtration rate and no parenchymal injury related to PCNL [2], [3]. However, more studies have to be performed regarding this issue.
Alternative managements, such as laparoscopic kidney stone surgery, have been considered approachable especially where kidney stones exist with concomitant ureteropelvic junction
obstruction [4], [5]. Laparoscopic stone removal, either performed retroperitoneoscopic or transperitoneal has been reported in several studies [4], [5], [6].
Some studies have assessed the beneficial of laparoscopic stone removal in cases of large kidney stones [7], [8], [9]. However, the effectiveness of laparoscopic stone removal compared to PCNL in treating large or multiple kidney stones still has to be validated. Two meta-analysis has been reported the comparison of laparoscopic approach and PCNL in treating kidney stones and found the comparable results between those two managements. At present, several clinical trials have been performed since the last meta-analysis study comparing laparoscopic approach and PCNL for removal of kidney stones. Therefore, we conducted an update meta-analysis to compare the effectiveness and safety of laparoscopic pyelolithotomy and PCNL in the treatment for large and/or multiple kidney stones.
Methods
Literature selection
Literatures from Medline, EMBASE, Science Direct, Cochrane Library, and Google Scholar databases published from inception to March 2019 were assessed using keywords related to laparoscopic pyelolithotomy, PCNL, and kidney stones. All eligible studies were addressed by tested the strategies and modified them if necessary. We use “related article”
feature on Medline to obtain any additional and grey literatures. We also assessed all the citations of any relevant articles to broaden our search. Study searches were restricted by adult patients and English language.
Inclusion and exclusion criteria
The inclusion criteria for this study were: (1) randomized controlled trials (RCTs), case control or cohort studies that compare the outcomes of laparoscopic pyelolithotomy with PCNL, (2) Cases with large kidney stone burden (>1.5 cm), single or multiple.
We excluded literatures other than English, meta- analysis studies, studies included ureteral stones, and studies with pediatric populations.
Data extraction, quality assessment, and outcomes
First author assessed and screened the literatures according to inclusion and exclusion criteria.
Author screened the title, abstract and eventually the full paper of potentially relevant studies. The following outcomes were extracted from included studies:
Operation time, post-operative hospital stay, stone-free status, overall complications, post-operative bleeding (hemoglobin drop and the rate of blood transfusion), post-operative fever, prolonged urine leakage, and additional interventions. The quality of eligible studies was assessed using the Newcastle-Ottawa Scale.
Data analysis
Statistical analysis used a risk ratio (RR) for dichotomous data, whereas mean difference (MD) was used for continuous data. Fixed or random effects model was used based on the p value of heterogeneity. The data heterogeneity was assessed by calculating the degree of inconsistency (I2). The heterogeneity was determined low (I2 = 25-50%), moderate (I2 = 51–75%), and high (I2 > 75%). The effects of pooled data were determined by test for overall effect (Z-test), and p < 0.05 was considered significant. All calculations were performed using Review Manager version 5.3.
Results
A thorough search identified 731 studies.
After comprehensive assessment, authors identified 16 publications that met inclusion criteria. Thirteen citations were full papers and three were conference publications.
Therefore, these 16 studies were included in our meta- analysis which involved 1044 cases: 501 cases underwent laparoscopic pyelolithotomy and 543 cases for PCNL. The flowchart for literature searching and selection process is shown in Figure 1. Authors analyzed 9 outcomes:
Operation time in 16 studies, post-operative hospital stay in 13 studies, stone-free rate in 13 studies, overall post- operative complications in 13 studies, prolonged urine leakage in 10 studies, post-operative fever in 9 studies, drop in hemoglobin, blood transfusion rate, and additional intervention in 8, 12, and 6 studies, respectively.
Figure 1: Flowchart of studies searching
Baseline characteristics and summary of findings included in this study were presented in Tables 1 and 2. Eight studies were RCTs and another eight studies were non-RCTs. The imaging modalities used in the studies were plain X-ray of kidney-ureter- bladder, ultrasonography, fluoroscopy, computed tomography, and nephrostography.
Operation time and post-operative hospital stay
All studies reported the operative time that included 1044 patients, 501 patients in laparoscopic group and 543 patients in PCNL group (Figure 2).
High level of heterogeneity was showed in the analysis (I2 = 98%). Analysis of the data showed that laparoscopic pyelolithotomy had significantly longer operative time than PCNL (MD, random-effect 35.45, 95% CI 13.12–
57.79, p = 0.002).
The length of post-operative hospital stay was reported in 13 studies, with the total of 479 patients in laparoscopic group and 521 patients in PCNL group (Figure 3). No significantly difference was found
regarding the length of post-operative hospital stay between the two groups (MD, random-effect 0.45, 95%
CI −0.14–1.03, p = 0.13, I2 = 90%).
Stone-free rate
Thirteen studies assessed the stone-free rate between laparoscopic group and PCNL group. Total of 986 patients were analyzed comprising 471 patients in laparoscopic group and 515 patients in PCNL group
(Figure 4). We found that laparoscopic had more significant benefit on stone-free rate than PCNL (RR, random-effect 1.17, 95% CI 1.09–1.25, p < 0.0001).
Moreover, moderate heterogeneity was found in this analysis (I2 = 59%).
Overall complications
Thirteen studies reported the overall complications after surgery. Total of 435 patients in Table 1: Characteristics of studies included in the review
First author Year Study
design Treatments
approach Patients
number Age (years) Percentage
of males BMI (kg/m2) Stone burden Types of stones NOS score
Agrawal [10] 2015 RCT Lap 18 40 66.7 NA 3.70 ± 0.55 cm2 Pelvis 4
PCNL 20 41.2 70 NA 3.90 ± 0.60 cm2
Al-Hunayan [9] 2011 RCT Lap 55 41.2 ± 11.7 58.2 NA 2.40 ± 0.40 cm Pelvis 6
PCNL 50 38.5 ± 11.9 56 NA 2.50 ± 0.40 cm
Aminsharifi [11] 2013 RCT Lap 60 44.5 ± 14.8 61.7 NA 3.59 ± 0.73 cm Pelvis 5
PCNL 30 43.8 ± 15.0 66.7 NA 3.53 ± 0.73 cm
Basiri [12] 2014 RCT Lap 30 38.5 ± 15.9 NA 26.10 ± 6.70 3.6 (2.8-4.4) cm Pelvis, staghorn 6
PCNL 30 42.1 ± 14.3 NA 25.80 ± 7.30 3.3 (2.7-4.2) cm
Fawzi [13] 2015 RCT Lap 30 42.4 ± 12.1 NA NA 3.20 ± 0.60 cm Pelvis 4
PCNL 30 44.6 ± 11.4 NA NA 3.40 ± 0.50 cm
Gaur [14] 2001 Non-RCT Lap 42 39.1 (8–65) NA NA 2.0 (1.0–4.8) cm Pelvis, multiple, calyx 4
PCNL 47 34.4 NA NA 2.9 (2.0–3.8) cm
Goel [7] 2003 Non-RCT Lap 16 38.9 (21–60) 62.5 NA 3.6 (3.2–4.5) cm Pelvis 5
PCNL 12 41.4 (20–62) 66.7 NA 4.1 (3.5–5.2) cm
Haggag [15] 2013 Non-RCT Lap 10 38.8 ± 12.2 50 NA 6.50 ± 1.20 cm2 Pelvis 4
PCNL 42 42.0 ± 13.2 73.8 NA 4.19 ± 2.03 cm2
Lee [16] 2014 Non-RCT Lap 45 56.0 ± 13.7 73.3 24.90 ± 3.80 4.93 ± 3.03 cm Pelvis, staghorn, multiple 6
PCNL 39 54.3 ± 13.0 71.8 25.10 ± 4.10 4.63 ± 1.65 cm
Li [17] 2014 RCT Lap 89 55.6 ± 10.9 NA 23.29 ± 3.37 2.93 ± 1.02 cm Pelvis, staghorn 6
PCNL 89 53.2 ± 11.5 NA 22.67 ± 3.19 3.00 ± 0.96 cm
Meria [8] 2005 Non-RCT Lap 16 42 (21–63) NA NA 2.5 (2.0–3.3) cm Pelvis 5
PCNL 16 45 (24–69) NA NA 2.6 (2.0–4.0) cm
Perlin [18] 2011 Non-RCT Lap 5 NA NA NA >2 cm Pelvis 5
PCNL 20 NA NA NA >2 cm
Singh [19] 2014 RCT Lap 22 45.6 ± 14.2 NA NA >3 cm Pelvis 6
PCNL 22 44.9 ± 13.8 NA NA >3 cm
Tefekli [20] 2012 Non-RCT Lap 26 36.5 ± 11.1 NA 25.34 ± 3.55 7.46 ± 2.25 cm2 Pelvis 6
PCNL 26 37.1 ± 10.0 NA 25.25 ± 3.03 7.18 ± 1.51 cm2
Tepeler [21] 2009 Non-RCT Lap 16 41.2 ± 16.8 NA NA 8.82 ± 3.20 cm2 Pelvis 4
PCNL 16 43.9 ± 14.1 NA NA 8.49 ± 2.60 cm2
Xiao [22] 2018 RCT Lap 51 55.3 ± 14.8 68.7 24.95 ± 4.57 13.77 ± 5.18 cm2 Pelvis, staghorn, multiple 6
PCNL 54 53.7 ± 12.5 72.2 25.80 ± 4.70 12.59 ± 6.58 cm2
RCT: Randomized controlled trial, Lap: laparoscopic pyelolithotomy, PCNL: Percutaneous nephrolithotomy, BMI: Body mass index, NA: Not available, NOS: Newcastle-Ottawa Scale; Age, BMI and stone burden were shown as mean ± SD or mean (minimum-maximum).
Table 2: Summary of findings included in meta‑analysis
Study, year Treatments Operative time
(minutes) Drop in Hb
(g/dL) Hospital stay
(days) Stone free
(%) Post-operative complications (%) Urine
leakage (%) Post-operative
fever (%) Post-op blood
transfusion (%) Additional intervention (%)
Agrawal, 2015 Lap 145.88 ± 35.54 NA 4.50 ± 2.47 NA 22.22 NA 16.67 0.00 NA
PCNL 76.20 ± 9.21 NA 3.50 ± 1.33 NA 15 NA 10.00 0.00 NA
Al-Hunayan, 2011 Lap 130.60 ± 38.70 NA 4.50 ± 1.90 100 16.36 5.45 5.45 5.45 NA
PCNL 108.5 ± 18.70 NA 4.40 ± 1.40 96 24 0.00 18.00 6.00 NA
Aminsharifi, 2013 Lap 120.5 ± 39.94 1.38 ± 0.88 4.00 ± 0.70 100 3.33 0.00 NA 3.33 NA
PCNL 98.10 ± 23.38 1.76 ± 0.94 3.50 ± 0.70 76.67 16.67 10.00 NA 6.67 NA
Basiri, 2014 Lap 149.00 ± 31.00 0.85 ± 0.50 3.40 ± 1.20 88 13.33 0.00 NA 3.33 10.00
PCNL 107.00 ± 26.00 1.88 ± 1.20 2.16 ± 0.70 64 20 10.00 NA 13.33 13.33
Fawzi, 2015 Lap 132.70 ± 33.40 1.10 ± 0.56 4.10 ± 1.70 100 20 10.00 6.67 0.00 NA
PCNL 85.40 ± 16.20 1.80 ± 1.20 3.40 ± 1.50 90 16.67 3.33 13.33 10.00 NA
Gaur, 2001 Lap 116.25 ± 10.00 NA 3.90 ± 1.00 100 30.95 NA 2.38 0.00 0.00
PCNL 152.00 ± 10.00 NA 5.40 ± 1.00 82.98 40.43 NA 10.64 12.77 12.77
Goel, 2003 Lap 142.20 ± 58.75 NA 3.80 ± 2.25 NA 31.25 6.25 0.00 NA NA
PCNL 71.60 ± 12.50 NA 3.00 ± 0.75 NA 25 0.00 8.33 NA NA
Haggag, 2013 Lap 131.00 ± 22.11 NA 2.30 ± 0.64 80 30 0.00 30.00 0.00 NA
PCNL 51.19 ± 24.39 NA 3.70 ± 1.40 78.57 35.71 2.38 21.43 4.76 NA
Lee, 2014 Lap 163.70 ± 78.20 NA 4.64 ± 3.34 91 NA NA NA NA NA
PCNL 116.80 ± 44.40 NA 4.76 ± 1.60 64.10 NA NA NA NA NA
Li, 2014 Lap 90.87 ± 33.40 0.90 ± 0.50 4.50 ± 2.30 97.75 6.74 3.37 3.37 0.00 0.00
PCNL 116.80 ± 44.40 1.70 ± 1.30 4.30 ± 1.30 89.89 16.85 0.00 13.48 1.12 2.25
Meria, 2005 Lap 129.00 ± 37.50 0.60 ± 0.30 8.25 ± 3.00 87.50 25 12.50 NA 0.00 12.50
PCNL 75.00 ± 26.25 1.80 ± 1.10 7.00 ± 1.75 81.25 18.75 0.00 NA 6.25 18.75
Perlin, 2011 Lap 143.00 ± 10.00 NA 8.50 ± 1.00 100 NA NA NA NA NA
PCNL 116.00 ± 10.00 NA 6.20 ± 1.00 90 NA NA NA NA NA
Singh, 2014 Lap 91.82 ± 16.51 NA NA 95.45 9.09 NA 9.09 0.00 4.55
PCNL 87.27 ± 23.84 NA NA 72.72 9.09 NA 9.09 0.00 27.27
Tefekli, 2012 Lap 138.40 ± 51.19 1.00 ± 0.57 3.90 ± 2.50 100 7.69 3.85 NA 0.00 NA
PCNL 57.92 ± 21.12 1.70 ± 1.12 2.30 ± 0.50 88.46 7.69 0.00 NA 3.85 NA
Tepeler, 2009 Lap 126.40 ± 34.80 3.07 ± 3.86 3.20 ± 1.60 NA NA NA NA NA NA
PCNL 95.80 ± 37.80 6.08 ± 4.51 3.00 ± 2.10 NA NA NA NA NA NA
Xiao, 2018 Lap 135.70 ± 35.50 0.40 ± 0.30 5.30 ± 1.80 88.24 21.57 11.75 5.88 3.92 11.77
PCNL 101.90 ± 41.20 1.70 ± 1.30 4.70 ± 2.40 64.82 38.89 3.70 20.37 12.96 31.48
Lap: Laparoscopic pyelolithotomy, PCNL: Percutaneous nephrolithotomy, NA: Not available; Operative time, drop in Hb and hospital stay were presented as mean ± SD
laparoscopic group and 468 patients in PCNL groups was analyzed (Figure 5). The meta-analysis revealed that PCNL had significantly higher complications than laparoscopic (RR, fixed-effect 0.71, 95% CI 0.55 – 0.93, p = 0.01, I2 = 0%).
Post-operative bleeding
The outcomes observed were post-operative drop of hemoglobin and the need for blood transfusion post-operatively. Eight studies reported post- operative hemoglobin drop, comprising 288 patients in laparoscopic group and 291 patients in PCNL group (Figure 6). Moderate heterogeneity was observed in the analysis (I2 = 53%). The result of analysis showed that laparoscopic pyelolithotomy had a significant lower hemoglobin drop than PCNL (MD, random-effect −0.89, 95% CI −1.14–(−0.65), p < 0.00001).
Twelve publications reported regarding blood transfusion. However, two studies reported that no blood transfusion needed on both groups; therefore, the analysis on these two studies was not estimable. Ten studies with the total of 875 patients (419 patients in laparoscopic group and 456 patients in PCNL group) were analyzed (Figure 7). We found that laparoscopic had a significantly lower blood transfusion than PCNL (RR, fixed-effect 0.33, 95% CI 0.16–0.66, p = 0.002, I2 = 0%).
Post-operative fever and urine leakage There were nine studies including total of 699 patients to be included in the analysis of post- operative fever (Figure 8). There was higher incidence of post-operative fever in PCNL group than laparoscopic group (RR, fixed-effect 0.45, 95% CI 0.28–0.72, p = 0.0009, I2 = 15%).
Figure 3: Forest plot of post-operative hospital stay between laparoscopic and Percutaneous nephrolithotomy Figure 2: Forest plot of the length of operative time between laparoscopic and Percutaneous nephrolithotomy
Ten studies reported regarding prolonged
urine leakage after surgery with the total of 732 patients (353 in laparoscopic group and 379 in PCNL group) (Figure 9). We found that there were no significantly Figure 5: Forest plot of overall post-operative complications between laparoscopic and Percutaneous nephrolithotomy
Figure 4: Forest plot of stone free rate between laparoscopic and Percutaneous nephrolithotomy
Figure 6: Forest plot of drop in hemoglobin between laparoscopic and Percutaneous nephrolithotomy
differences between two groups regarding post- operative urine leakage (RR, fixed-effect 1.76, 95% CI 0.90–3.42, p = 0.10, I2 = 0%).
Additional interventions
The data from total of 508 patients from 6 studies, including 250 from laparoscopic and 258 Figure 9: Forest plot of prolonged urine leakage between laparoscopic and Percutaneous nephrolithotomy
Figure 7: Forest plot of post-operative blood transfusion between laparoscopic and P Percutaneous nephrolithotomy
Figure 8: Forest plot of post-operative fever between laparoscopic and Percutaneous nephrolithotomy
from PCNL were pooled into analysis (Figure 10).
Twelve patients out of 250 patients in laparoscopic group were needing additional procedures, whereas 38 from 258 patients in PCNL group need additional interventions. PCNL showed a significantly higher additional interventions rate than laparoscopic (RR, fixed-effect 0.35, 95% CI 0.19–0.62, p = 0.0004, I2 = 0%).
Discussion
At present, PCNL is considered as a gold standard and recommended as the first choice of management for kidney stones above 2 cm and also for complex renal stones. However, laparoscopic kidney stone removal, either retroperitoneal or transperitoneal, has gained wide attention since the first report by Gaur et al. [23]. They recommended laparoscopic stone removal for stones not successfully treated to shockwave lithotripsy or PCNL. Meta-analysis comparing laparoscopic pyelolithotomy and PCNL for treating patients with large kidney stones have been performed previously [24], [25]. However, some randomized studies obtained different results. We carried out this meta-analysis with several additional literatures for further validation.
This study showed that laparoscopic approach achieved a higher stone-free rate than PCNL. In solitary stone, this could possible due to the stone can be removed clearly using laparoscopic approach, meanwhile in PCNL the stones or the fragmented stones could move into smaller calyces and make it harder to reached. The additional interventions might be needed due to the residual stone. This could be explained on why the additional treatment rate was higher in PCNL group than laparoscopic group. Previous study suggested the more advance additional technical approaches needed to improve stone free rate [26]. Some studies evaluated the effect of laparoscopic approach on single kidney stone cases and showed insightful results as
laparoscopic approach had comparable results to PCNL for single pyelum kidney stones [8], [9]. However, laparoscopic approach might be better option for cases with complex kidney stones, such as multiple calyceal stones and complex staghorn stones.
Most included studies showed PCNL group has less operative time than laparoscopic approach. However, Gaur et al. and Li et al. reported conflicting results [14], [17].
They showed that PCNL was associated with longer operative time than laparoscopic approach. Some factors may affect operative time, including operator’s experience, option of approach, armamentarium used, and variability among patient’s anatomy [17]. Previous study showed the superiority of laparoscopic retroperitoneal approach as this approach less involving the vascular area than those with PCNL [17].
Laparoscopic group was associated with lower incidence of post-operative complications compared to PCNL. A decrease in hemoglobin and blood transfusion rate were more detected in PCNL group. This issue might happen due to the fact that kidney parenchymal was disturbed and invaded during the procedure. This could relate to the higher rate of complications following PCNL as compared to those in laparoscopic group.
While most of the included studies reported lower estimated blood loss in laparoscopic group, Goel et al.
and Agrawal et al. found the opposite findings. They reported greater blood loss in the laparoscopic group compared with PCNL group, although not statistically significant [7], [10]. There was a higher incidence of post-operative fever in PCNL group compared with laparoscopic group. However, there was a comparable result between two approaches in terms of prolonged urine leakage postoperatively.
The main drawback of laparoscopic technique is the requirement of more advance expertise as well as the learning curve of the surgeon performing it. This study showed the longer operation time in laparoscopic technique than PCNL. Nevertheless, outweighed by several beneficial outcomes in laparoscopic group, this technique is worth doing not only as an alternative management, but also as a main treatment options for large kidney stone cases.
Figure 10: Forest plot regarding additional intervention between laparoscopic and Percutaneous nephrolithotomy
This study might have some possible drawbacks that should well thought of: (1) Not all of the studies included were RCTs, this might lead to some biases. More RCTs surely needed to confirm the outcomes of this meta-analysis. (2) Some data were extracted from conference abstract [13], [18], [21] that we cannot justify their methods in detail. However, these data were valuable to be included in this study.
Conclusion
Laparoscopic stone removal provided higher stone free rate and lower post-operative complications than PCNL. Laparoscopic approach could stand as a main treatment option in large kidney stone/s beside PCNL. Nevertheless, more large volume RCTs studies needed to justify the outcomes of this study.
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